Brachial plexus birth palsy

Children’s Hospital Boston’s Brachial Plexus Program provides comprehensive care—including evaluation, diagnosis, consultation, surgery, non-surgical therapies and follow-up care, which may include:

• observation:
  • Most brachial plexus birth palsies will heal on their own. Your doctor will monitor your child closely.
  • Many children improve or recover by 3 to 12 months of age. During this time, ongoing exams should be performed to monitor progress.

• physical therapy (and/or occupational therapy):
  • Therapy is recommended to help maximize use of the affected arm and prevent tightening of the muscles and joints.
  • With the teaching and guidance of therapists, parents learn how to perform range of motion (ROM) exercises at home with their child several times a day. These exercises are important to keep the joints and muscles moving as normally as possible.

• Botox injections: may be used (mainly for the shoulder) to:
  • help with joint motion
  • rebalance muscles
  • prevent contractures and shoulder dislocations

• surgery: Children who continue to have problems three to six months after birth may benefit from surgical treatment
   

Your child’s doctors have several surgical options for treating brachial plexus birth palsy, including:

•  microsurgery (10 to 20 percent of all BPBP surgery)
  • recommended if recovery is still inadequate three to six months after birth
  • to repair or reconstruct the injured nerves
  • can be “nerve grafts,” usually from the leg (sural nerves) between nerve root and nerve to muscle
  • can be “nerve transfers” from other areas of the brachial plexus (or other areas of the body): for more serious BPBP (avulsion)
  • nerve reconstruction is best performed between 3 and 9 months of life and is usually not beneficial for children beyond 1 year of age
     
• tendon transfers
  • involves separating the tendon from its normal attachment and reattaching it to a new location
  • allows a healthy muscle to help a weaker or injured muscle perform its desired function
  • usually performed around the shoulder to improve the ability to raise the arm, but may be used in forearm, wrist or hand
  • done between 1 year of age and adulthood
  • patients usually in a cast for four to six weeks after surgery
  • extensive post-operative therapy
  • in some cases, shoulder weakness may cause limitations in motion that aren’t amenable to tendon transfers
     
• open reduction of the shoulder joint (capsulorraphy)
  • reducing (placing the humeral head back in joint) and surgically tightening loose tissue around the shoulder joint
  • usually performed when persistent muscle weakness has caused shoulder joint instability or dislocation
  • performed:
    • through a surgical incision (“open”) -or-
    • using arthroscopy
      • pencil-sized camera is inserted into the shoulder via smaller incisions
  • often performed in conjunction with other surgical procedures
     
• osteotomy
  • procedure in which bones are cut and reoriented
  • may improve upper extremity function by better positioning the hand and arm
  • most commonly performed on the humerus (upper arm bone) or forearm
     
• free muscle transfers
  • typically using muscle (gracilis) from patient’s leg(s)
  • extensive surgery requiring reconnection of blood vessels and nerves under microscope
  • used only when there are no local muscles in the arm or hand to replace dysfunctional muscles

Complications after surgery

Complications after surgery are uncommon but can occur, and can be either temporary or permanent. These include:

• stiff joints—can be treated with physical therapy
• pain from nerve damage (very unlikely)
• muscle atrophy due to incomplete recovery
• disability from incomplete recovery
• the biggest worry is that the arm and hand will not get as close to normal as hoped

Generally, surgery does not make children worse, but does not always lead to full recovery.

Caring for your child after surgery

After your child’s BPBP surgery, her Children’s pediatric orthopedist and physical therapist will advise you of physical therapy exercises you can do with your child at home. Her doctor can also help you plan a nutritional program and a personal exercise regimen to optimize your child’s recovery.

Long-term outlook

The good news is that—either spontaneously or with therapy—most of our young patients recover fully or nearly fully by the time they’re 6 to 12 months old. Some may even begin to recover when they’re just 6 weeks old. Less than half of children with BPBP will need nerve surgery. Some require tendon transfers. The outcomes from these surgeries are favorable for improved long-term function.

If needed, your child’s rehabilitation team will work with you and your child to learn home exercises that are important to her recovery. Most parents perform range of motion (ROM) exercises at home with their child many times a day for several years. These exercises are important for keeping the joints and muscles moving as normally as possible.

Coping and support

At Children’s Hospital Boston, we understand that a hospital visit can be difficult, and sometimes overwhelming. So, we offer many amenities to make your child’s—and your own—hospital experience as pleasant as possible. Visit The Center for Families for all you need to know about:

• getting to Children’s
• accommodations
• navigating the hospital experience
• resources that are available for your family

In particular, we understand that you may have a lot of questions when your child is diagnosed with BPBP. Will this affect my child long term? When can she return to her sports and activities? Children’s can connect you with extensive resources to help you and your family through this stressful time, including:

• patient education: From doctor’s appointments to physical therapy and recovery, our nurses and physical therapists will be on hand to walk you through your child’s treatment and help answer any questions you may have—Why will my child need surgery? Are there non-surgical options? How long will her recovery take? How should we manage home exercises and physical therapy? We’ll help you coordinate and continue the care and support your child received while at Children’s.
   
• parent-to-parent: Want to talk with someone whose child has been treated for BPBP? We can often put you in touch with other families who’ve been through the same process that you and your child are facing, and who will share their experiences.
   
• faith-based support: If you’re in need of spiritual support, we’ll connect you with the Children’s chaplaincy. Our program includes nearly a dozen clergy— representing Protestant, Jewish, Muslim, Roman Catholic and other faith traditions—who will listen to you, pray with you and help you observe your own faith practices during your hospital experience.
   
• social work: Our social workers and mental health clinicians have helped many families in your situation. We can offer counseling and assistance with issues such as coping with your child’s diagnosis, stresses relating to coping with illness and dealing with financial difficulties.